Article Text

An evidence and consensus based guideline for acute diarrhoea management
  1. HARRY BAUMER, Consultant Paediatrician
  1. Derriford Hospital
  2. Plymouth, Devon, UK

    Abstract

    OBJECTIVE To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home.

    EVIDENCE A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated.

    CONSENSUS An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panellists' responses. Consensus was predefined as 83% of panellists agreeing with the statement.

    RECOMMENDATIONS Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200–250 mOsm/l) given “little and often”. A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated.

    VALIDATION The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.

    • diarrhoea
    • gastroenteritis
    • Delphi consensus
    • guideline
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    Diarrhoea is defined as a change in bowel habit for the individual child resulting in substantially more frequent and/or looser stools. Acute diarrhoea, most frequently the result of infectious intestinal disease (IID), represents a major cause of consultations in general practice. Djuretic et al estimated that each year there are 526 000 consultations in children age under 5 years with IID.1 Using 1994 population data this equates to about 1 in 6 children per year consulting their general practitioner with an episode of IID, though this figure may be an overestimate as some may attend more than once. Sixteen per cent of all paediatric medical presentations to accident and emergency departments are for children with diarrhoea, with or without vomiting.2Hospital admissions for children with gastroenteritis rose by about 6% from 1989 to 1994 and currently account for approximately 7% of all paediatric admissions in the under 5 age group.3 In 1994 hospital admission rates of 1 child in 150 under 5 years for IID were reported and the cost of inpatient care had risen from that in 1991.4 Gastroenteritis admission rates are significantly higher in young children from more deprived areas.5Children with similar severity of illness on attendance may be managed differently (unpublished data) and junior doctors make many of the initial decisions.2

    We set out to develop this guideline with the following aims: (1) to improve the process and outcome of care for children attending hospital with diarrhoea; (2) to promote consistency of care so that patients with almost identical clinical problems would be managed in the same way; and (3) to inform, educate, and improve the clinical decision making of the junior clinicians who see most of these children initially.

    Scope of the guideline

    The guideline deals with children who have diarrhoea, with or without vomiting, rather than with a defined diagnosis, as the guideline should assist clinicians in diagnosis prior to management of a particular condition.6 Children presenting with vomiting alone or with chronic diarrhoea (more than seven days duration) are not considered. We present a summary version of the full guideline (which can be obtained from the corresponding author, or theArchives of Disease in Childhood website,www.archdischild.com) to which reference should be made for clarification or further information. The authors assume that health care professionals will use general medical knowledge and clinical judgement in applying the recommendations in this document to the management of individual patients. These recommendations may not be appropriate for use in all circumstances.

    Method of development

    Recommendations made are based on statements derived from a systematic review of published literature and refined by a three round Delphi consensus development process. The literature search used the following databases: Medline (1966 to June 1998), Embase (1980 to June 1998), and Cochrane (to June 1998). The following mesh headings and text words were used: diarrh*; diarrhea infantile; diarrhea to 14 years; gastroenteritis; differential diagnosis; diagnos*; incidence; prevalence; aetiology; etiology; dehydration; patient admission; fluid therapy; intravenous; intravenous treatment; rehydration solution; administration, oral; enteral nutrition; faeces; feces; lactose intolerance; enteral; differential diagnosis. General search terms for the type of study required were also used (for example, for diagnostic procedures, the search “sensitivity and specificity or predictive value of tests or diagnostic errors or screening or diagnosis or sensitivity or specificity” was used).

    Explicit inclusion criteria were set: articles that addressed the clinical questions identified, a scientific review of the literature, and a review or clinical guideline written by a national body. Articles were excluded if opinion based. Included articles were critically appraised using a standard proforma, and recommendations were graded using a standard grading scheme (see ). The derived statements, together with the original papers referred to4 7-67 and appraisals were sent to a Delphi panel consisting of 39 medical and nursing staff who regularly manage children with diarrhoea, with or without vomiting. The final guideline based on the literature review and predefined consensus agreement (agreement by at least 83% of panelists) is in the form of an algorithm (flow diagram or decision tree) shown in fig 1. Each box is numbered, and key decision points are allocated a letter, with recommendations explained in the text. Throughout, the word “admit” is defined as follows: any admission to a paediatric facility with paediatric trained staff for observation, further investigation, and management regardless of the expected length of stay.

    Figure 1

    The final guideline. A, B, C, airway, breathing, circulation; CRP, c reactive protein; ESR, erythrocyte sedimentation rate; SPA, suprapubic aspirate; Ur, urea; Cr, creatinine; Elec, electrolytes; Bicarb, bicarbonate; Na, serum sodium (mmol/l); ORS, oral rehydration solution; NGT, nasogastric tube; IV, intravenous; IVI, intravenous infusion; CHD, congenital heart disease; U&E, urea and electrolytes.

    The guideline

    A: DIFFERENTIAL DIAGNOSIS OF CHILD PRESENTING WITH DIARRHOEA

    Statement—There are no published data on the relative probabilities of possible diagnoses in the child presenting to hospital with diarrhoea.

    A table of differential diagnoses (table 1) is shown derived from published texts18 65 (Vb, D) and consensus opinion, not intended to be comprehensive, but rather to act as an aide memoir to the clinician. (Based on Level Vb evidence and Delphi consensus, Grade D recommendation.)

    Table 1

    Broad differential diagnosis of the child presenting with acute diarrhoea (with or without vomiting). The latter diagnoses are more likely to present chronically

    It is essential that the clinician recognise any life threatening causes of diarrhoea, such as intussusception19 (Vb, D), surgical abdomen21 (Vb, D), and haemolytic uraemic syndrome20 (III, C). Features suggestive of these conditions are identified, and although these features may occur in acute gastroenteritis the likelihood of a different aetiology is increased and should be actively sought.

    Recommendation on differential diagnosis

    The following clinical features should alert the clinician to look for causes other than acute viral gastroenteritis for a child's diarrhoea with or without vomiting:

    • Abdominal pain with tenderness, with or without guarding (Vb, D)

    • Pallor, jaundice, oligo/anuria, bloody diarrhoea (III, C)

    • Systemically unwell, out of proportion to the level of dehydration (Vb, D)

    • Shock (Vb, D).

    Features are based on evidence levels shown and Delphi consensus agreement.

    B: ESTIMATION OF SEVERITY OF DEHYDRATION

    The management of gastroenteritis consists of correction of dehydration (rehydration) and maintenance of hydration. An accurate estimate of the level of dehydration is required to achieve this end.

    Statement—The severity of dehydration is most accurately assessed in terms of weight loss as a percentage of total body weight (prior to the dehydrating episode). This is the “gold standard” against which other “tests” are measured25 (I, A).

    In a prospective cohort study of children between 3 and 18 months of age in Egypt, Duggan and colleagues26 (III) found that “prolonged skinfold”, dry oral mucosa, sunken eyes, and “altered neurological status” were the best clinical signs correlating with dehydration as determined by post-rehydration weight gain. In a similarly designed study, with children under 4 years old, Mackenzie and colleagues27 (III) found “decreased skin turgor”, decreased peripheral perfusion, and deep (acidotic) breathing to be the best clinical indicators of dehydration. A urea of >6.5 mmol/l on serum blood sample and pH<7.35 on blood gas were positive investigations associated with dehydration. However the sensitivity and specificity of all these signs were low.

    In both studies mild to moderate dehydration on clinical assessment was found to represent weight loss of 3–5%. Those with severe signs (circulatory collapse) had weight loss of 9–10%. These studies correlate well with the WHO guidance on dehydration assessment.66

    Recommendation

    See table 2 for estimating level of dehydration if weight loss not available. (Level III and Delphi consensus, Grade C recommendation.)

    Table 2

    Assessment of severity of dehydration (if in doubt err by overestimating % dehydration) B

    C: BLOOD TESTS

    Statement—There is no direct evidence indicating when serum electrolytes should be measured in a child with diarrhoea.

    The indication from cohorts of children in the UK with gastroenteritis is that derangement of electrolytes is rare37 61 62 with 1% of admissions having hypernatraemia and no reports of hypokalaemia or hyponatraemia. Even when there is derangement of electrolytes in the serum, this is a result of relative losses of salts and water. There will still be a total body depletion of sodium in hypernatraemic patients.25 Oral rehydration solution (ORS) with appropriate amounts of solutes and given in the correct quantity is sufficient in itself to correct electrolyte abnormalities41 (II, B).42 It is thus unnecessary to measure electrolytes in those children who will be rehydrated with ORS. All children having intravenous rehydration should have urea and electrolytes (U&E) measured, as hypernatraemia will alter the rate at which intravenous rehydration fluids are given and further measurements of U&E should be made as rehydration progresses.25 In addition the American Academy of Pediatrics (AAP) suggest in their practice parameter40(Va, D) that electrolyte levels should be measured in moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes, and where a “doughy” feel to the skin may indicate hypernatraemia.

    Recommendation on blood tests

    The child who presents with diarrhoea, with or without vomiting, should have blood taken for urea/creatinine, electrolytes, and bicarbonate in the following circumstances:

    • Severe dehydration with circulatory compromise

    • Moderate dehydration where a “doughy” feel to the skin might indicate hypernatraemia

    • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes.

    (Based on Level Va evidence and Delphi consensus, Grade D recommendation.)

    D: MANAGEMENT OF REHYDRATION

    Following the evidence of several randomised controlled trials in the USA, Europe, and developing countries49 51 52 54 (II, B), it is acknowledged that ORS is quicker in the correction of dehydration and acidosis and safer than intravenous therapy25 40 (I, A).63 The overall failure rate of oral rehydration therapy (ORT, defined as the persistence or recurrence of signs of dehydration and other clinical indications requiring the need for intravenous rehydration) was 3.6% (95% confidence interval 1.4 to 5.8).63 Moreover the use of ORT appears to reduce the risk of seizure during correction of hypernatraemic dehydration52 (II, B).

    Recommendation in mild–moderate dehydration

    • Children who have mild–moderate dehydration secondary to acute gastroenteritis should have their deficit estimated (3–8%) and replaced with ORS (30–80 ml/kg) given “little and often” over 3–4 hours, whenever this is practically possible.25 40 44 63 (Level I and Delphi consensus, Grade A recommendation.) (An attempt was made to define “little and often” further. The literature discusses the correct administration of ORS and recommends that it be given in 5 ml aliquots every 1–2 minutes. Only if this is well tolerated with no vomiting may the size of the aliquots be increased, with decreasing frequency.25 41 42 63 64 However this regime was thought to be too labour intensive for the UK by the Delphi panelists and did not achieve consensus.) (Definition of “whenever practically possible”: this implies that the child's carer is willing and able to carry this out under supervision.)

    • Where the child's carer is not willing and able to carry this out, or when it is required overnight, rehydrate by continuous nasogastric tube infusion (preferred) or intravenous infusion. (Level Va and Delphi consensus, Grade D recommendation.)

    • Regularly assess success of rehydration (for example, two hourly). If no improvement in clinical signs of dehydration or worsening signs, consider nasogastric tube or intravenous infusion. (Level Va and Delphi consensus, Grade D recommendation.)

    E: COMPOSITION OF ORS

    In the 1970s the WHO adopted a glucose–electrolyte solution that contained 90 mmol/l of sodium for the treatment of diarrhoea. Since then there have been many controlled trials looking at the ideal concentration of electrolytes and carbohydrate in ORS. A recent multicentre trial in four developing countries found that reduced osmolarity ORS (224 mmol/l) had advantages over standard ORS (311 mmol/l) in the treatment of non-cholera diarrhoea46 (II, B). In developed countries diarrhoea tends to be isotonic (mainly rotavirus induced) and the European Society of Paediatric Gastroenterology and Nutrition (ESPGAN)44 published guidelines on the ideal composition of ORS for children of Europe. Since this publication, studies from Finland47 (II, B) and a multicentre trial46 (II, B) have confirmed that reduced osmolarity ORS is preferable in European children. See table 8 for the composition of ORS recommended and those commercially available.

    Table 8

    Composition of fluids for intravenous and oral rehydration in acute gastroenteritis

    Table A1

    Levels of evidence and grade of recommendation

    A recent meta-analysis of 13 clinical trials examining the effect of rice based ORS on total stool output and duration of diarrhoea showed that there appeared to be some benefit in those with cholera, but in those with non-cholera diarrhoea no benefit was shown48(I, A).

    Recommendation on the composition of ORS

    • ORS used for rehydration of children with acute gastroenteritis in the UK should contain: 60 mmol/l sodium, 20 mmol/l potassium, ⩾25 mmol/l chloride, and 74–111 mmol/l glucose. (Commercial solutions conforming to this include Dioralyte and Diocalm Junior.) (Level I and Delphi consensus, Grade A recommendation.)

    F: MAINTENANCE OF HYDRATION/PREVENTION OF DEHYDRATION

    The child who was not dehydrated and the child who is no longer dehydrated following rehydration should be allowed free fluids, and be encouraged to drink more than usual.25 40 Tables 3 and 4show standard methods for calculating ORS requirements. Table 5suggests when to send a stool sample to the laboratory.

    Table 3

    Calculation of oral rehydration solution requirements in the dehydrated child with acute gastroenteritis D

    Table 4

    Calculation of ORS maintenance fluid requirements F

    Table 5

    When to send a stool to the laboratory for microscopy, culture, sensitivity, and virology in acute diarrhoea

    Recommendation on maintenance fluids

    • To prevent primary dehydration or recurrence of dehydration, allow unrestricted fluids (for example, milk or water). Ensure that at least maintenance fluids are taken. (Level Va and Delphi consensus, Grade D recommendation.)

    G: REFEEDING FOLLOWING REHYDRATION

    Good evidence exists to show that children who are breast fed should continue breast feeding throughout the rehydration and maintenance phases of their therapy24 56 (III, C). In so doing they reduce the risk of dehydration, pass smaller volumes of stool, and recover quicker.

    In children with acute gastroenteritis who are formula fed, the vast majority (over 80%) can be successfully managed following rehydration with continued feeding of undiluted non-human milks55 (I, A). This is now recommended practice, including the introduction of age appropriate diets in children who are weaned.25 40 45 67

    Recommendation on refeeding (see table 6)

    • Breast feeding children should continue to breast feed through the rehydration and maintenance phases of their acute gastroenteritis illness. (Level III and Delphi consensus, Grade C recommendation.)

    • In the dehydrated child with gastroenteritis who is normally formula fed, feeds should stop during rehydration and restart as soon as the child is rehydrated (four hours). (Level I and Delphi consensus, Grade A recommendation.)

    Table 6

    Management of feeding during acute gastroenteritis G

    H: CRITERIA FOR ADMISSION OF CHILDREN WITH GASTROENTERITIS

    Statement—There are no published trials comparing outpatient with inpatient management, nor are there any recommendations made by eminent bodies.

    Recommendations for admission

    The following reached Delphi consensus agreement.

    • Children presenting to hospital with acute gastroenteritis who are severely dehydrated should be admitted to hospital.

    • Those children with mild–moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3–4 hours) and maintenance of hydration (2–3 hours).

    • Those children at high risk of dehydration on the basis of young age (infants <6 months22 23 (III, C)), high frequency of watery stools (more than eight per 24 hours22 24 (III, C)) or vomits (more than four per 24 hours22 24 (III, C)) should be observed in a hospital paediatric facility for at least 4–6 hours to ensure adequate maintenance of hydration.

    • Those children whose parents or carers are thought to be unable to manage the child's condition at home successfully should be admitted to hospital.

    (Based on Delphi consensus.)

    I: ROLE OF MEDICATION

    There is evidence from several randomised controlled trials that antidiarrhoeal and antimotility agents are not clinically beneficial in the management of acute childhood gastroenteritis, and their side effect profile is unacceptable (reviews of trials25 40(I, A)).

    Recommendation on medication (see table 7)

    • Infants and children with acute gastroenteritis should not be treated with antidiarrhoeal agents.

    Table 7

    Guide to drug treatment in acute gastroenteritis G

    (Level I and Delphi consensus, Grade A recommendation.)

    Key recommendations

    All gained consensus. The level of evidence and strength of recommendation follow each statement

    • Level of dehydration is assessed using a table modified from WHO criteria (III, C)

    • Those with no dehydration (<3%) should continue with their normal fluids at at least maintenance levels (Va, D)

    • Those with mild–moderate dehydration (3–8%) should have their deficit estimated and replaced over four hours with oral rehydration solution (glucose based and reduced osmolality, 200–250 mOsm/l) (I, A)

    • Oral rehydration solution should be given in small aliquots frequently. If vomiting persists it should be given by nasogastric tube (preferred) or intravenous rehydration commenced (I, A)

    • No routine investigations of U&E are required unless intravenous rehydration is commenced or hypernatraemia is suspected clinically (Va, D)

    • Children with mild–moderate and severe dehydration should be admitted to hospital for rehydration (consensus, D)

    • Following rehydration (four hours) normal feeds should be recommenced (I, A)

    • There is no place for antidiarrhoeal medication (I, A)

    Discussion

    This guideline for the management of the child who presents with acute diarrhoea to hospital was developed using a systematic literature review and formal consensus using a Delphi panel. It is striking that for this type of management guideline the level of published evidence on which recommendations are based is poor. During the Delphi process, 41 statements were made, of which 13% were based on level I evidence, 25% on level III, 52% on level V, and 10% on textbook recommendation or Delphi panel contributions. The final guideline consists of 34 consensus statements (83% of the total presented to the Delphi panel).

    This Delphi method of guideline development has several advantages. The use of a nationally selected panel of clinicians allows for a consensus view to be gained on those issues on which published evidence is lacking. Thus a comprehensive guideline can be produced with recommendations on all areas of management, which is likely to be acceptable and practical. It is likely to then need only simple local tailoring prior to being adopted. This method ensures that the guideline is clear on the level of evidence for each recommendation so that the clinician knows which are based on strong evidence from the literature and which on consensus.

    There are also potential weaknesses with this approach. For the areas where there is little or no good evidence in the literature the process relies on the opinion of the participating panellists. It is therefore possible to tap into collective error—the whole group managing children in a certain way based on historical practice rather than evidence. The importance of stating the level of evidence for each recommendation is again highlighted, so individual clinicians and local guideline development panels can immediately see which are based on strong evidence and which are not. The method was time consuming, with the whole process taking one year from initiating literature review to implementation of the guideline. It is therefore possible that high quality evidence is published in the intervening period which cannot be included in the recommendations at the time of publication, since it did not go through the Delphi process.

    Further research would be beneficial on many of the decision points discussed, for example: the assessment of risk of dehydration in the child in a developed country, outpatient versus inpatient management of rehydration, nasogastric versus oral rehydration, and cereal versus glucose based ORS for rehydration (and palatability) in a developed country.

    We intend to review the evidence and consensus on which this guideline is based in approximately three years from the date of its completion (May 1999).

    Acknowledgments

    The authors acknowledge Children Nationwide Medical Research Fund for their generous funding of this research, and Jeanette Taylor-Meek for effective administration of the Delphi process. The following Delphi panelists are acknowledged for contributing a great deal of time and effort: Ackland F (paediatric consultant), Arrowsmith W A (paediatric consultant), Bailey R (A&E consultant), Barker R (paediatric nurse), Bennett Britton S (paediatric consultant), Boon A W (paediatric consultant), Boyle R (paediatric specialist registrar), Cade A (paediatric specialist registrar), Carter E (paediatric consultant), Charlton C P J (paediatric consultant (gastroenterology)), Cutting W A M (paediatric consultant), Cutts J (paediatric nurse), Devane S (paediatric consultant), Edge J (paediatric consultant), Ehrhardt P (paediatric consultant), Gleeson E (A&E specialist registrar), Green C (paediatric consultant), Hewertson J (paediatric consultant), Hodges S (paediatric consultant), Huynh H (paediatric specialist registrar), Jefferson I (paediatric consultant), Jenkins H (paediatric consultant (gastroenterology)), Kershaw C (paediatric consultant), Laurent S (paediatric consultant), Lewis H M (paediatric consultant), Marcovitch H (paediatric consultant), McGovern M C (paediatric specialist registrar), McGraw M E (paediatric consultant), McLain B (paediatric consultant), Mirfattahi M M B (paediatric consultant), Puntis J (paediatric consultant (gastroenterology)), Rutter N (paediatric consultant), Sajjanhar T (paediatric consultant (A&E)), Smith R (paediatric consultant), Smith S (paediatric consultant (A&E)), Stephens S (paediatric specialist registrar), Sullivan C (paediatric consultant), Thomas S (paediatric specialist registrar), Wells L (paediatric specialist registrar).

    Appendix

    Table A1 summarises levels of evidence and grade of recommendation.

    References

    Commentary

    No doctor can hope to keep up to date with the literature across a broad spectrum of practice. National guidelines are helpful where they bring together all the evidence from research and synthesise it into a series of recommendations showing the strength of that evidence. Dr Armon and colleagues have used a formal consensus process to provide guidance, and this raises a number of important questions. It happens that there are also recent guidelines on acute diarrhoea management published by Murphy in 1998,1-1 and by the American Academy of Paediatrics (AAP) in 1996.1-2 If guidelines are to provide truly evidence based recommendations, they must be developed rigorously. How do these three guidelines measure up to the standards published by the Royal College of Paediatrics and Child Health?1-3

    They are all based on a detailed review of the literature, and two contain explicit levels of evidence for the recommendations. They were not conducted with the rigour of the systematic reviews in the Cochrane database. For example, the review of Dr Armon et al did not include textword searching, and none included hand searching through journals not covered by the electronic databases. There was no attempt to establish whether unpublished trials exist: publication bias can result when journals are more likely to publish trials with positive results. The AAP guideline was supplemented by a technical report and focused on three specific aspects of management.

    The consensus guideline of Dr Armon et alinvolved consultants from several specialties, nurses, and specialist registrars. This is important in ensuring that the perspectives of all those involved contribute to the guidance. However, with only two nurses on the panel, the Delphi process would have allowed consensus to be achieved, even when both nurses disagreed. The lack of any primary care or parental input to the process undermines the section on admission criteria, for which research evidence appears to be lacking. The assistance of parents with recent experience of managing acute diarrhoea in their children would have been most valuable in formulating written material for parents.

    The key message to emerge from all three guidelines is the safety and effectiveness of oral rehydration solutions, even in children with moderate (up to 8%) dehydration without shock. Additionally, that administration of the calculated deficit over a few hours is simple and effective. Crucial to achieving success with oral rehydration solution is the time that it takes carers to administer. All three guidelines recommend the correction of dehydration orally over a period of four hours. This would mean for some infants and children a rate of up to 80 ml/kg over four hours. However, in none of six controlled trials that I looked up,1-4-1-9 was this rate of oral administration attempted, and in only one1-7 was it achieved. Is this recommendation therefore actually consistent with the evidence, or indeed better than six or eight hours for achieving rehydration? It was rated an A grade in Dr Armon and colleagues' guideline.

    Where does this leave the UK practising paediatrician? Given the limitations of the three guidelines, there is a risk that important evidence may be missing or inadequately interpreted. We still need a well conducted evidence based guideline, involving all professional groups, primary care and parents, and based on a rigorous literature review. However, the studies that support these guidelines are compelling, and we should not wait before using a multiprofessional approach to getting oral rehydration therapy into practice at the local level. Read all three guidelines as a starting point in reviewing or developing local guidelines, but check back to the key original publications. I will leave it to you, the reader, to judge how much extra value you get from Dr Armon and colleagues' consensus statements.

    References

    1. 1-1.
    2. 1-2.
    3. 1-3.
    4. 1-4.
    5. 1-5.
    6. 1-6.
    7. 1-7.
    8. 1-8.
    9. 1-9.

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    Supplementary materials

    • Guideline for the management of children presenting to hospital with diarrhoea, with or without vomiting

      Paediatric Accident and Emergency Research Group:

      Dr Kate Armon, Prof. Terence Stephenson, Dr Ursula Werneke, Miss Phillippa Eccleston and Dr Roderick MacFaul

       

      Dr Kate Armon. BmedSci BMBS MRCP MRCPCH DCH DRCOG

      Research Fellow, Academic Division of Child Health,

      School of Human Development,

      University of Nottingham, NG7 2UH.

      Prof. Terence Stephenson, BSc BM DM BCh FRCP FRCPCH,

      Professor of Child Health and Honorary Consultant Paediatrician,

      Academic Division of Child Health

      School of Human Development,

      University of Nottingham

      Dr Ursula Werneke, MD MSc MRCPsych

      Specialist Registrar

      Maudsley Hospital

      London SE5 8AZ

      Miss Philippa Eccleston, BSc (hons) RGN RSCN .

      Nurse Researcher,

      Academic Division of Child Health,

      School of Human Development,

      University of Nottingham.

      Dr Roderick MacFaul MB ChB FRCP FRCPCH DCH

      Consultant Paediatrician

      Pinderfields General Hospital

      Aberford Road

      Wakefield

      Correspondence to:

      Dr kate Armon

      Conflict of interest: none

      Funding: Children Nationwide Medical Research Fund

       

      Acknowledgements

        • The following Delphi panellists for contributing a great deal of time and effort:

        Ackland F (Paed. Cons.), Arrowsmith W A (Paed. Cons.), Bailey R (A&E Cons), Barker R (Paed. Nurse), Bennett Britton S (Paed. Cons.), Boon A W (Paed. Cons.), Boyle R (Paed. SpR.), Cade A (Paed. SpR.), Carter E (Paed. Cons.), Charlton C P J (Paed. Cons. (gastro)), Cutting W A M (Paed. Cons.), Cutts J (Paed. Nurse), Devane S (Paed. Cons.), Edge J (Paed. Cons.), Ehrhardt P (Paed. Cons.), Gleeson E (A&E SpR), Green C (Paed. Cons.), Hewertson J (Paed. Cons.), Hodges S(Paed. Cons.), Huynh H (Paed. SpR.), Jefferson I (Paed. Cons.), Jenkins H (Paed. Cons. (gastro)), Kershaw C (Paed. Cons.), Laurent S (Paed. Cons.), Lewis H M (Paed. Cons.), Marcovitch H (Paed. Cons.), McGovern M C (Paed. SpR.), McGraw M E (Paed. Cons.), McLain B (Paed. Cons.), Mirfattahi M M B (Paed. Cons.), Puntis J (Paed. Cons. (gastro)), Rutter N (Paed. Cons.), Sajjanhar T (Paed. Cons. (A&E)), Smith R (Paed. Cons.), Smith S (Paed. Cons. (A&E)), Stephens S (Paed. SpR.), Sullivan C (Paed. Cons.), Thomas S (Paed. SpR.), Wells L (Paed. SpR.).

        Key: Paed. = Paediatric, Cons. = Consultant, SpR = Specialist Registrar, A&E = Accident and Emergency, Gastro = Gastroenterology

        • Children Nationwide for their generous funding of this research
        • Jeanette Taylor-Meek for effective administration of the Delphi process
        • Abdominal pain with tenderness/guarding and/or bilious vomiting (?surgical)
        • Pallor, jaundice, oligoanuria, bloody stool (?HUS)
        • Systemically unwell, out of proportion to the level of dehydration (other infections, surgical, CAH etc)
        • Shock
        • Signs are ordered in each column by severity.
        • If a pre-illness accurate weight is available calculate deficit from weight loss.
        • Pinch test � Pinch skin of abdomen. Skin recoils instantly = normal, 1-2 sec = mild/moderate, >2sec = severe.
        • Children who are dehydrated are thirsty and do not normally refuse ORS.
        • Give fluid little and often. If the child is vomiting decrease volumes and increase frequency (every 5-10 minutes).
        • Where carers are not willing/able to do this under supervision (or child is asleep) then rehydrate by NGT.
        • Suitable ORS are Dioralyte, Diocalm Junior or Electrolade.
        • A history of blood +/- mucous in the stool
        • Systemically unwell, severe or prolonged diarrhoea
        • If the child is admitted to hospital (local policy)
        • A history suggestive of food poisoning
        • Recent travel abroad
        • Definition of diarrhoea
        • Differential diagnosis
        • Abdominal pain with tenderness +/- guarding (Vb,D)
        • Pallor, jaundice, oligo/anuria, bloody diarrhoea (III,C)
        • Systemically unwell, out of proportion to the level of dehydration (Vb,D)
        • Shock (Vb,D)
        • Estimation of severity of dehydration
        • Investigations (plasma)
        • Severe dehydration with circulatory compromise
        • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
        • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
        • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
        • Further boluses
        • Hypernatraemic dehydration
        • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
        • Ward management of rehydration
        • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
        • Urea and Electrolyte investigation in mild to moderate dehydration
        • Rehydration / maintenance and ongoing losses
        • Failure of ORS
        • Maintenance of hydration/ prevention of dehydration
        • Re-feeding following rehydration
        • Information
        • Admission criteria
        • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
        • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
        • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
        • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
        • Risk of dehydration
        • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
        • More than 8 significant* diarrhoeal stools in the last 24 hours.
        • A �significant� vomit is anything more than an effortless, small volume, possett.
        • Replacement of losses in the child at risk of dehydration.
        • Criteria for admission of children with gastroenteritis
        • Literature concerning the need for stool culture
        • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
        • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
        • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
        • A history suggestive of food poisoning (no literature, Delphi consensus)
        • Recent travel abroad (Level Vb and Delphi consensus, grade D)
        • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
        • Role of medication in gastroenteritis
        • Salmonella typhi � ciprofloxacin until sensitivities available
        • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
        • Giardia � metronidazole
        • Amoebiasis � metronidazole and Diloxanide furoate.
        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
        • Your child�s weight today is
        • He/She needs to take in at least of fluid over a 24 hour period.
        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
        • Stop all solid food until the vomiting has settled
        • If your baby is breast fed continue to feed on demand
        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
        • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
        • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
        • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
        • AVOID fatty foods and sugary foods.
        • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
        • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
        • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
        • The diarrhoea has blood in it
        • Your child becomes more sleepy, lethargic or irritable than usual
        • Your child has 5 or more vomits in 24 hours
        • Your child has 9 or more loose poos in 24 hours
        • The diarrhoea continues for more than 7 days
        • Try to change the nappy as soon as it is dirty.
        • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
        • Apply barrier cream or Vaseline liberally.
        • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
        • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
        • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.

         

         

        Key words

        Diarrhoea, gastroenteritis, Delphi consensus, guideline

        Contents

         

         

         

        Page

        Quick reference guideline: Algorithm and associated tables 1-7

        4

        Abstract

        9

        Context, background information and date for review

        11

        Technical report on the guideline development process

        14

        Annotations A-S discussing evidence base for decision points in the algorithm

        16

        Associated tables 8-12

        35

        References

        40

        Implementation study

        43

        Suggested audit measures

        44

        Appendix 1. Definition of levels of evidence and grades of recommendation

        45

        Appendix 2. Parent information sheets

        46

        Appendix 3. Care pathway used in implementation

        49

        Appendix 4. Appraisal review document

        53

         

         

         

         

        Table 1: Broad differential diagnosis of the child presenting with acute diarrhoea (+/- vomiting). The latter diagnoses are more likely to present chronically.

        NB. The following features may be indicative of diagnoses other than acute viral gastroenteritis:

        • Abdominal pain with tenderness/guarding and/or bilious vomiting (?surgical)
        • Pallor, jaundice, oligoanuria, bloody stool (?HUS)
        • Systemically unwell, out of proportion to the level of dehydration (other infections, surgical, CAH etc)
        • Shock
        • Signs are ordered in each column by severity.
        • If a pre-illness accurate weight is available calculate deficit from weight loss.
        • Pinch test � Pinch skin of abdomen. Skin recoils instantly = normal, 1-2 sec = mild/moderate, >2sec = severe.
        • Children who are dehydrated are thirsty and do not normally refuse ORS.
        • Give fluid little and often. If the child is vomiting decrease volumes and increase frequency (every 5-10 minutes).
        • Where carers are not willing/able to do this under supervision (or child is asleep) then rehydrate by NGT.
        • Suitable ORS are Dioralyte, Diocalm Junior or Electrolade.
        • A history of blood +/- mucous in the stool
        • Systemically unwell, severe or prolonged diarrhoea
        • If the child is admitted to hospital (local policy)
        • A history suggestive of food poisoning
        • Recent travel abroad
        • Definition of diarrhoea
        • Differential diagnosis
        • Abdominal pain with tenderness +/- guarding (Vb,D)
        • Pallor, jaundice, oligo/anuria, bloody diarrhoea (III,C)
        • Systemically unwell, out of proportion to the level of dehydration (Vb,D)
        • Shock (Vb,D)
        • Estimation of severity of dehydration
        • Investigations (plasma)
        • Severe dehydration with circulatory compromise
        • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
        • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
        • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
        • Further boluses
        • Hypernatraemic dehydration
        • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
        • Ward management of rehydration
        • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
        • Urea and Electrolyte investigation in mild to moderate dehydration
        • Rehydration / maintenance and ongoing losses
        • Failure of ORS
        • Maintenance of hydration/ prevention of dehydration
        • Re-feeding following rehydration
        • Information
        • Admission criteria
        • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
        • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
        • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
        • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
        • Risk of dehydration
        • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
        • More than 8 significant* diarrhoeal stools in the last 24 hours.
        • A �significant� vomit is anything more than an effortless, small volume, possett.
        • Replacement of losses in the child at risk of dehydration.
        • Criteria for admission of children with gastroenteritis
        • Literature concerning the need for stool culture
        • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
        • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
        • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
        • A history suggestive of food poisoning (no literature, Delphi consensus)
        • Recent travel abroad (Level Vb and Delphi consensus, grade D)
        • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
        • Role of medication in gastroenteritis
        • Salmonella typhi � ciprofloxacin until sensitivities available
        • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
        • Giardia � metronidazole
        • Amoebiasis � metronidazole and Diloxanide furoate.
        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
        • Your child�s weight today is
        • He/She needs to take in at least of fluid over a 24 hour period.
        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
        • Stop all solid food until the vomiting has settled
        • If your baby is breast fed continue to feed on demand
        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled